Aging, suffering, and the inevitability of death: Let's keep it real, and ignore the quacks

My friend Paul Taylor, longtime journalist and former executive at the Pew Trusts, has just published a new book called “This Is Getting Old: Two Boomers and Their Generation at Dusk”. It has two main topics. The first is an often-disturbing analysis of the impact of the “Boomer generation” as a whole, focused on their (our) massive accumulation of money, fighting for society’s resources to be directed to us, and shockingly, away from those who need it most, children. There are clearly many different indviduals in this generation, as well as subgroups (since boomers were born 1946 to 1965, the usual characterizations of us in our youth, activism in the late 1960s, obviously are only about the older part of that cohort). He makes the point that not only did this generation, as many before, get more conservative as they aged, but that only a portion of them were ever progressive. And the contrast between their generosity to their own children and grandchildren, and their parsimony toward most of society’s children is, at least coincidentally (as he states it), or definitely (as I think) about the color, race, and ethnicity of the majority of today’s children. Did I say this was shameful? If not, I do!

The other focus of the book is the aging of his, their, and our generation, focusing particularly on one couple (a terrific, impressive, warm and active couple), but also full of data on what is happening to all of us. Which is the same thing that happened to everyone before us, getting old and eventually dying. We may be dying older, and dying of different things, and (many of us) having more healthy and productive years before we die, but we all die. And for many of us, perhaps most of us, as all through history, that dying will be preceded by a period – which can be short or be many years – of suffering, of being sick, in pain, losing our mental faculties, or all of these. Guaranteed. While billionaires are being quite successful in avoiding (at least for themselves) the other of that famous pair, taxes, avoiding death is, even for them, only a science fiction cryogenic dream for them that has not yet happened. Thank goodness. If there are any people that the future does NOT need preserved for them to deal with, it is the billionaires most assiduously working on it!

So, we need to remember not only the inevitability of death, but the suffering that so often precedes it. We boomers have been watched it in our parents, our older relatives, and, sadly, many of our peers. It is well to remember the myth of Tithonus, who was granted eternal life by Zeus, but not eternal youth. He continued to age, alive and living sicker and more decrepit. A more modern self-deception: a few decades ago, I was the only physician in a health policy class. Each week one student had to make a presentation to the class on a particular topic. The student who addressed the issue of “long term care” did present data, but then added that in their opinion the need for long-term care would decrease because people were taking better care of themselves, exercising and eating better and not smoking. I pointed out that this would obviously increase the need for long-term care, as people would less often die young from heart attacks and more often live older and older (if not eternally, like Tithonus) with more and more care needs. I suspect I even said something like “if you want to decrease the need for long term care, have people smoke, drink, eat poorly, not exercise and drop dead in the 40s and 50s”.

But that student, and others, were young. Somehow, they conflated living a more healthful lifestyle, and having better health in the near and medium term, with not ever confronting getting old, sick, and dying. That is purely wishful thinking. While living more healthfully is a good idea, it cannot prevent the inevitable. And yet, many people, even today, believe this that somehow they can and (more venally and evilly) are selling it to others. Some of these ideas are commonly associated with folks like Secretary of Health and Human Services Robert F. Kennedy, Jr. (how painful to associate that name and that title!) and the MAHA (Make America Healthy Again) movement. Like the MAGA (Make America Great Again) of Donald Trump, the key point is the “again”. In the case of MAGA, it depends on what your definition of “great” is – probably America was if it means slavery, racism, subjugation of women, and constant wars, with military budgets making up the biggest part of public spending, the funding of which comes disproportionately from those with lower incomes.

In terms of MAHA, while there may be a bit less subjective flexibility about defining “healthy” than “great”, there is definite disagreement about the road to health. For example, a recent study by the Edelman Trust Barometer produced the table below. About a quarter to a third
of Americans believe each of these falsehoods, and 70% believe at least one, with a whole bunch of folks who “don’t know”. Edelman calls these claims “false or unproven”, which is generous. To a greater or lesser degree, they are all false. The most dangerous are the claims about vaccines, which are good, and to a large degree the reason that boomers and others are likely to live as long as they are. As a t-shirt I have seen correctly asserts “Vaccines cause adults”!

 

 

Unpasteurized (ie, raw) milk has in fact caused lots of deaths because of bacterial contamination. Testimonials from dairy farmers who drink it all the time are not valid for urbanites who are consuming it days after milking, when the bacteria in it that would have been killed by pasteurization has had time to multiply, The other false claims may not cause death, but sure can cause suffering; I suffered a lot of dental cavities as a kid before our water was fluoridated. Fluoride is definitely helpful to dental health (excessive amounts can cause unsightly, but NOT dangerous, mottling of teeth). Avoiding acetaminophen in pregnancy can cause pain. And on animal protein: it is not more healthful than plant protein, it is in fact, generally less healthful. As is animal fat (e.g, tallow, lard). 

These false claims are relatively easy to refute, although it is not easy to convince people who believe them that they are wrong; these are two different things. But what of the amazing plethora of other magical health claims, today’s equivalents of snake oil (in promises for great health, not to mention quackery). Early in his book, Taylor writes 

Don’t pick up this book expecting to find the magic formula for staying forever young. I ain’t got one. You’re better off cruising TikTok, where a bustling industry of anti-aging influencers serves up a bottomless banquet of science and quackery. They treat aging as a curable condition, death an avoidable fate. 

Sigh. It would be wonderful if these nostrums could keep you healthy and keep you from dying. But they don’t. That doesn’t keep them from being a “bustling” (and profitable!) industry.

Three points:

1) Natural is not necessarily better or safer. That is a fallacy. Anything that actually has biologic effects can have the ones you want, and the ones you don’t (side effects). If it doesn’t have any biologic effect, it’s not helping either.

2) Don’t be a sucker. Yes, Big Pharma is evil, but there is much better data on whether and how its products work than those of the MAHA-hood.

3) If it sounds to good to be true, it probably is.

Raw milk, vaccines, and RFK, Jr: Some dates worth remembering

Some dates worth remembering:

1862: Louis Pasteur discovers the eponymous process of pasteurization (based on work done by Lazzaro Spallanzani 100 years earlier), first used in beer and wine, but most importantly in milk. As the process is gradually introduced (the first US state required it in 1947, the federal government for interstate commerce in 1973). It took a while, but with its introduction the frequency of serious and often life-threatening infections coming from unpasteurized (= “raw”) milk, including streptococcus, typhoid, typhus, and TB, among others, dramatically decreased. Health was improved.

2024: The US President-elect, Donald Trump, announces that he will nominate Robert F. Kennedy, Jr., who advocates the drinking of unpasteurized milk, to the cabinet post of Secretary of Health and Human Services.

1952: During the last major polio epidemic in the US, a friend comes to visit our family on a Saturday to see my new baby sister. On Monday, she comes down with polio and spends the rest of her life in a wheelchair. My parents are worried about their children having been infected, more about the greater risk to 3-year-old me than the baby, as polio in infants was uncommon. I do not get clinical polio (see * below) and soon thereafter receive both the Salk (injection) and later the Sabin (oral) polio vaccines. During this decade I also come down with clinical cases of measles, mumps, German measles (rubella), and chicken pox. The last was quite unpleasant, but I didn’t die and had no significant after-effects. The vaccine against measles (and mumps and rubella) were released in 1963. The rates of these diseases, especially measles which caused the most deaths, plummet. Most measles outbreaks since have been in populations in which people did not immunize their children, notably in 2019 among Hasidic Jews in Brooklyn.

As a young doctor at a public hospital in the 1970s, one of the common and feared infections we saw in the pediatric emergency room was that caused by the bacteria Hemophilus influenza b (not the same as the virus influenza). It commonly caused ear infections, but also very serious meningitis, and, most scary to us, epiglottitis, in which the epiglottis, the piece of tissue in your throat that prevents you from breathing in food, swells very large very fast and can completely cut off a child’s breathing unless a breathing tube can be placed in time (and it is difficult with the swelling). In 1985, the vaccine against H flu b was introduced, and these infections and deaths almost disappeared. Varicella (chicken pox) vaccine was not released until 1995, and the rate of those infected (and then later infected with shingles, a resurgence of the same virus, known as Varicella-Zoster) plummeted. Before the vaccine was released, about 4 million cases of chicken pox, with over 10,000 hospitalizations and 100 deaths, occurred (mostly among children) annually in the US.

2024: The US President-elect, Donald Trump, announces that he will nominate Robert F. Kennedy, Jr., who believes all vaccines are bad and should be avoided, to the cabinet post of Secretary of Health and Human Services.

The difference between individual and public health is important, and bears repeating.  For the individual, getting a disease (infectious or not) is 0% or 100%. If something happens to “one in a million” people it is very rare (including serious reactions to vaccines, which do not, incidentally, include autism) but if you are the one, it is 100% for you. On the other hand, if something affects 99% of people, but you are in the 1%, you are lucky. Public health looks at trying to prevent (or contain, if they are infectious) diseases by looking at the impact of disease, or preventive measure (e.g., vaccines, pasteurization) on the population**. Pointing to individual exceptions (“my grandfather drank a quart of whisky and smoked two packs of cigarettes a day and lived to be 100”, or “we drank raw milk all the time and we’re healthy”) does not change that unless an subgroup that is not susceptible can be identified (e.g., biological males do not get cervical cancer – although they still should be immunized against HPV as they can transmit it). Some things may decrease the risk; those drinking raw milk direct from the cow on their farm are at lower risk of infections than those who consume it after it has been shipped and had days, or longer, to become infected. Folks who are skeptical of modern medicine often emphasize “prevention”, but this is not a magic incantation. Vaccines are one of the few things we have that actually prevent serious disease. Also avoiding foods that have a significant likelihood of being infected – tainted meat, shellfish, water infected with sewage (water remains the largest cause of death, through infant diarrhea; the main reason commercial campaigns to replace safe breastfeeding with formula that needs to be rehydrated are terrible), or raw milk.

Human progress is not unidirectional. There are often steps backwards, motivated by misinformation, financial gain, fantasies, (some people’s interpretation of) religious beliefs, political gain, and others. The appointment and confirmation of Kennedy would be a big step backward. The implementation of the policies he advocates will take us back more than a century.

There is a – very important – place for evidence and truth.

 

*Even though poliovirus infects almost everyone exposed who is susceptible, not everyone who is infected with poliovirus gets clinical polio; it is about 10%. Measles, on the other hand, also infects almost 100% of susceptible people, and virtually everyone infected gets clinical disease.

**It is worth noting that even the practice of one-on-one clinical medicine is based on applied epidemiology, the science of studying disease in populations. Why we may suspect a certain condition in a person with certain symptoms is because, in a population of people who are similar and who have these symptoms, these are the common causes. Same for treatments: we don’t say “well, the last person I saw with diabetes responded well to insulin, but you’re a different person, so let’s try digitalis.”